Smoke-Free or Freedom to Smoke?

By Margaret Davidson

Oct 28, 2011Oct 28, 2011

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HOW SOCIABLE, EVEN GLAMOROUS, it all once seemed. Today, the lighting of a cigarette is commonly regarded as the epitome of antisocial behavior. Leading men and women of the silver screen once puffed away before audiences of all ages, but today the New York State Department of Health announces in full-page ads that cigarettes "don't belong in youth-rated movies, period."

Cigarette smoking - having seen its romantic allure blown away by a whirlwind of health studies, education programs and advertising campaigns - is now at the center of a heated national debate. Controversial bans on smoking in public places divide the "right to smoke" crowd from those who demand to breathe smoke-free air. Questions over the legality of lighting up - and where one can do so - have ignited a feud that tests the boundaries of individual rights. Uncertainty remains about where the line should be drawn between personal choice and public health.

Attitudes toward smoking began to change significantly in 1964 when the U.S. Army Surgeon General's Office issued a report about the health risks to smokers, based largely on findings of VA hospital pathologist Oscar Auerbach. He meticulously established the correlation between smoking and lung cancer with research on thousands of human lung-tissue samples (another part of his research featured 86 beagles trained to smoke cigarettes).

Heeding the Army surgeon general's warning, waves of Americans began snuffing out, never to light up again. The percentage of adult Americans who smoked cigarettes dropped from about 42 percent in 1965 to 37 percent in 1970. In later years, the association between smoking and lung disease became clearer, and the cost of health care and insurance began to climb. The financial impact of smoking shifted from what it cost for a pack of cigarettes to what it cost in taxes and government-funded medicine.

In 1986, the conundrum no longer belonged only to the nicotine-addicted. That year, the surgeon general's office produced new alerts about the menace of secondhand smoke. "Scientific evidence indicates that there is no risk-free level of exposure to secondhand smoke," one report warned.

Today, little scientific question remains about the dangers of smoking. Smokers will, on average, live 13 to 14 fewer years than nonsmokers, according to the Centers for Disease Control and Prevention, which recognize cigarette smoking as the greatest preventable cause of death. About 438,000 deaths in the country each year are deemed to have been caused by smoking. That's more than the number of deaths from AIDS, automobile crashes, alcohol, cocaine, heroin, fire, homicide and suicide combined, according to the Institute of Medicine.

The same report calculates the economic ramifications of smoking in the billions of dollars. Lost work productivity resulting from tobacco-related death is estimated at about $92 billion per year, with related health-care expenditures at another $89 billion a year. Some question the estimates of health costs. In a macabre argument, they say the government saves money because smokers die at a younger age, thereby reducing Medicare funds needed for health care in their senior years.

Smoking can be tough to quit. Daryl Bly, 61, of Ripon, Wis., who smoked for about 35 years, says he made about 10 attempts but couldn't break the habit until he got connected with a smoking-cessation program designed for veterans. "They gave me a lot of ideas that I didn't think of to do," he says. The increasing price of cigarettes and his employer's new health initiative - taking $60 each month from the salaries of employees who smoked - served as strong incentives.

Bly is among about 400 military personnel and veterans in Wisconsin who have enrolled in Operation Quit Tobacco, which provides veterans with free coaching and a starter kit of nicotine patches or nicotine gum.

"Evidence-based counseling, combined with one of the FDA-approved medications, is the best prescription for quitting," says Dr. Michael Fiore, director of the University of Wisconsin Center for Tobacco Research and Intervention, which works with the veterans program. Similar smoking-cessation programs for current and former servicemembers are offered elsewhere in the country.

On average, veterans and servicemembers smoke more than the general population, Fiore says. Tobacco has accompanied soldiers to war as long as it has been available. Combat troops were once issued cigarettes in their rations, and servicemembers could purchase cigarettes at greatly reduced prices from the PX or ship's store. Gen. John "Black Jack" Pershing reportedly said his soldiers needed "tobacco as much as bullets" to win at war. Some have argued that, because the military introduced them to tobacco, the federal government should be liable for compensation to veterans with tobacco-linked ailments.

Fiore says the number of smokers in the military varies by branch of service, citing these 2005 rates: Army, 38 percent; Marines, 36 percent; Navy, 32 percent; and Air Force, 23 percent.

Among all Americans, about one in five smokes.

But smoking isn't as easy as it used to be.

According to the Campaign for Tobacco-Free Kids, 23 states have adopted smoking bans that include restaurants and bars, and four more have laws prohibiting smoking in restaurants but not in stand-alone bars. More such laws are in the works, often held up by heated debates over the variety of locales where restrictions are to be imposed.

Tavern owners have been among the most fervent opponents of smoking bans, arguing that if their customers can't smoke, they won't come at all, especially if smoking is allowed in establishments in nearby cities or states. Supporters of bans, on the other hand, argue that more customers will come and stay longer if they don't have to sit in a smoky haze. The battle has often developed into a war of numbers, fired off by both sides trying to emphasize the economic consequences.

"The evidence is clear that smoke-free laws protect health without harming business," the Campaign for Tobacco-Free Kids argues in its report. "Dozens of studies and hard economic data have shown that smoke-free laws do not harm sales or employment in restaurants and bars, and sometimes have a positive impact."

Not so, others say. "The problem with most studies that have been conducted is that they look at changes within a single city or municipality over time, rather than at the relative revenue changes over time in comparable smoke-free and smoke-friendly areas," Julian Sanchez wrote in Reason, which calls itself the magazine "of free minds and free markets."

Like the taverns, some veterans clubs face smoking bans that may threaten their continued existence. Some are already coping with empty bar stools as old veterans die and many new veterans don't join.

Legislators have debated whether members-only establishments should be exempt. In Pennsylvania, State Rep. Robert Belfanti has been seeking exemptions for small bars, social clubs and veterans organizations. Belfanti, who served in the Marine Corps during the Vietnam War, estimates that about half the veterans he represents are smokers. "When I was in the service, probably 80 percent of the people in the service smoked," he says.

While some veterans opposing the bans argue they fought for individual rights, including their right to smoke, others see it differently. "No one is taking away anyone's right to smoke," Robert Mehrman of Beverly, Mass., wrote in a letter on a newspaper Web site, but he said he also has a right to breathe clean air. "As a veteran, I believe that the government I fought for makes laws not to satisfy one individual's wishes but to serve the greater public good."

Why not let business owners decide whether to allow smoking, and customers decide whether they want to frequent a smoking or nonsmoking place? Opponents of that idea argue it would jeopardize the health of employees exposed to smoke in the workplace.

Nor will separating smokers, ventilating buildings or cleaning the air eliminate nonsmoker exposure to secondhand smoke, according to the surgeon general's report. "Conventional air-cleaning systems can remove large particles, but not the smaller particles or the gases found in secondhand smoke," it says.

The degree of secondhand smoke risk is often debated. ABC broadcaster John Stossel, known for his "Give Me a Break" segments, questioned the extent of risks in a 2006 report. He conceded that nonsmokers can be harmed by smokers but questioned the amount of exposure before harm is done. "Studies that followed nonsmokers who lived with smokers found some increase in lung cancer and heart disease," he acknowledged. "But they studied people who were exposed to lots of smoke, often shut in with chain smokers for years in claustrophobic situations like homes and cars. Even then, some of the studies found no effect. Nevertheless, it's been enough to launch a movement to ban smoking most everywhere."

Some have proposed tax incentives to businesses that ban smoking, or imposing ventilation requirements and higher license fees on businesses that permit smoking. Two University of Wisconsin-Madison professors, Robert Haveman and John Mullahy, have suggested the adoption of a system of tradeable smoke-pollution permits, as has been done by the Environmental Protection Agency, to help control emissions.

Smokers, too, are being creative in their responses. Reports are cropping up of "smoke-easies" and other illicit responses reminiscent of Prohibition days. Efforts are under way to make the lives of ostracized smokers more comfortable. For example, smoking tents and shacks have arisen outside taverns in Anchorage, Alaska.

As the controversy smolders, the rate of decline in the number of smokers has stalled. The anti-smoking lobby is calling on the FDA to assume more authority over tobacco. "There are more consumer health protections for dog food than there are for tobacco," an editorial on the American Medical Association's Web site said in urging federal action. Bipartisan bills were introduced last year in the House and Senate that would give the FDA greater authority, but, more than a year later, they had not reached a vote.

As state and local smoking bans proliferate, tobacco companies are creating new types of smokeless products. U.S. cigarette companies have been test-marketing "snus" (rhymes with goose), a small tobacco-filled pouch, similar to a tea bag, that users generally put between their upper lip and gum for about a half hour and then throw out. Unlike chewing tobacco, the user doesn't need to spit frequently. They have been used in Sweden for decades, and studies have indicated they are less harmful to smokers' health than cigarettes (ingredients for the Swedish product are a closely held secret).

In general, studies indicate users of smokeless products do not face the same risks as smokers, simply because of the way nicotine is ingested. However, medical experts warn they are not harm-free.

For smokers facing bans that force them outside for a quick smoke, Middleton's new six-pack of 21/2-inch-long (not counting the plastic filter) pipe-tobacco cigars promises "Perfect Size For Your Next Smoke Break!"

In the future, all such new tobacco products would have to receive FDA approval before marketing, if the proposed Family Smoking Prevention and Tobacco Control Act before Congress is enacted. The bill calls for the establishment of "tobacco product standards to protect the public health, but reserves to Congress the power to ban any tobacco products or reduce the nicotine level to zero."

Some worry that FDA involvement would give the appearance of a seal of approval to the products. Nicotine has already been determined to be potentially hazardous and, unlike the pharmaceutical products regulated by the FDA, cigarettes not only can cause harm to their users but also to those nearby.

Bans prohibiting smoking in an ever-widening range of locales may well help protect nonsmokers and deter smokers, but health advocates maintain more resources should be devoted to smoking cessation and preventing youth from taking up the habit. They want the federal government to exercise greater control and state governments to use settlements with major tobacco companies - and cigarette taxes - for tobacco cessation and prevention programs.

"The tragedy of tobacco addiction and the disability, disease and death it causes will not be resolved with a halfhearted response consisting of partial measures and weak policy," the American Lung Association says. "Tobacco use drops when states pass comprehensive smoke-free laws, increase tobacco taxes, adequately fund tobacco control and prevention programs, and actively counter the industry's marketing."